In our continuing exploration of innovative models of care, in this blog we will examine the efforts of the Cambridge Health Alliance (CHA) to advance primary care in the context of a diverse and vulnerable urban population. Located in the Boston area where it has served as a laboratory for testing innovations in care, the CHA has evolved into a model that integrates the physical, mental and social needs of its patients. Much of the work to date is described in their “Guide and Toolkit”. Incorporating the concepts discussed in our September 9th blog, the Alliance has developed a carefully constructed team approach to care. With the team at its core, the CHA model includes four other foundational components: With the triple aim as a guiding light, CHA has a sophisticated approach to mass customization of its services to meet the overall needs of each patient. The alliance has gone to great lengths defining the team and defining roles and responsibilities for 12 different team members, from providers and nurses, to volunteer health advisors and community resource specialists. They have also developed logistical guidelines to ensure optimal patient engagement and outcomes, as well as efficient and effective use of resources. Building on the concept of a core team that focuses holistic engagement with each patient, the alliance has built robust capabilities in population health and care management, enabling the integration of behavioral health and social determinants of health into the care environment. In population health, the alliance incorporated a data and reporting structure that makes it easy for care management staff to identify, prioritize and develop care plans for patients in need.